I don't advocate belaying pin orthopedics. The safest approach to any fracture or dislocation on shipboard is to splint the injury until it can be tended by a physician. As long as bone ends are not protruding through the skin, and there is no sign of compromised circulation or nerve damage, definitive treatment can be delayed for a few hours. However, if you're in the Tasman Sea when your shipmate trips over the spinnaker pole and sustains a fracture-dislocation of the ankle, and his foot turns numb and pale, you will have to reduce the ankle in order to save his foot.

An Orderly Approach to Skeletal Injuries

  1. Check the CMS. CMS = Circulation, Motor function, and Sensation. Numbness, weakness, or diminished circulation in the extremity distal to (beyond) the fracture or dislocation means that displaced bone or fracture fragments are stretching or pressing on vessels or nerves. The victim may lose his hand or foot if you don't recognize and correct the problem. Here's how to check the CMS.
      a. Circulation. Check the pulse at the wrist (just above the thumb side of the hand) or at the ankle (behind the inner knob), as appropriate. Then check the warmth and color of the fingers and toes. If they are cool compared to the uninjured side, and blue or pale instead of pink, the circulation is impaired.
      b. Motion. Ask the victim to move the joints below the injury.
      c. Sensation. Check for pain sensation by gently pinching the skin below the injury.
  2. Distinguish between bony injury and sprains or bruises. Decide whether the injury is a fracture or dislocation or just a contusion or sprain. This is simple when the limb is grossly deformed or bone is protruding through the skin. If it isn't deformed, ask the victim to move the extremity. If he can move it through a normal range of motion, it's probably not fractured, and definitely isn't dislocated. Next, gently press on the bone, starting a few inches from the injured area. If it is fractured, it will be quite tender, and you'll feel crepitus, a grinding sensation caused by the bone ends rubbing together.
  3. Inspect the skin. If bone is visible through an open wound, the victim has an open fracture. Open fractures are very serious injuries. They are usually contaminated with bacteria, and may be complicated by wound infection or osteomyelitis (bone infection).

How to Reduce a Fracture

If the injured limb is not deformed, splint it in the position in which you find it. If it is deformed, the fracture is displaced and needs to be reduced to bring the fragments back into proper alignment. Reduction of a displaced fracture will relieve stretching and pressure on nerves and blood vessels near the fracture; reduce bleeding from the bone ends; prevent a closed fracture from becoming an open fracture; relieve pain; and enable you to splint the fracture. Sling Construction. (See Fig .1.)

Open Fractures
Open fractures must be treated immediately. First, cover the wound with 4-inch-by-4-inch gauze pads soaked in antiseptic solution and clean the skin around the wound with antiseptic solution. Then, reduce the fracture by pulling on the limb until the deformity is corrected. Cover the wound with a bulky dressing and immobilize the limb in a splint. Give cefadroxil, one gram immediately, and 500 mg every 12 hours, and arrange for evacuation.

Splints You can use a ready-made splint or you can improvise with an oar, gaff, fishing rod, magazine, charts, or any of a number of other shipboard items. Always keep these principles in mind when applying a splint:

  • The splint should immobilize the joints above and below the fracture.
  • Apply longitudinal traction to a fractured limb before applying a splint and splint dislocated limbs in the position in which you find them.
  • The splint should be well padded, especially over bony prominences.
  • The splint should provide some compression over the fracture site but should never impair the circulation.

Common Upper Extremity Fractures

Collar Bone (Clavicle)
You will note swelling, tenderness, and deformity over the clavicle.

Treatment: Keep the arm in a sling until the victim can move the arm comfortably (seven to 10 days).

Elbow
Fractures of the elbow are usually obvious.

Treatment: Put the arm in a sling.

Forearm
Either or both forearm bones (ulna and radius) may fracture following a direct blow to the area.

Treatment: If the forearm is deformed and CMS is impaired, grasp the hand and pull gently but steadily on the limb until it looks straight and you can feel a strong pulse at the wrist. Then splint it and put the arm in a sling with the elbow flexed to 90 degrees.

Wrist If the injured wrist resembles an upside-down fork, it's fractured. But the absence of deformity doesn't mean that it's not fractured.

Treatment: Immobilize the wrist in a cock-up splint. Have the victim hold a balled-up pair of socks in the palm of his hand and place his wrist and hand on a firm, 10-inch-long splint. Then wrap a three-inch elastic bandage around the hand from the knuckles to the upper forearm and put the arm in a sling. If the fingers are cold and blue, you may be dealing with a fracture-dislocation. Grasp the victim's hand as though you were going to shake hands and pull straight out until the deformity is corrected. Then apply a cock-up splint.

Finger Fracture
Fingers consist of three long bones, the proximal (closest to the hand), middle, and distal phalanges. They are frequently fractured on shipboard.

Treatment: Reduce fractures of the proximal or middle phalanges by pulling on the finger until it looks straight. Then buddy tape the finger to the adjoining finger and encourage your patient to use the finger as normally as possible while the fracture heals.

Fractures of the Spine
Falling out of a bosun's chair never hurt anyone, but those hard landings on the deck have caused more than a few compression fractures of the vertebrae and fracture-dislocations of the spine. The latter is usually associated with signs of spinal cord injury, i.e., weakness and loss of feeling below the chest or waist.

Treatment: First, do a simple neurologic exam to rule out spinal cord injury. Have the victim raise his arms over his head against resistance and check his grip strength. Then have him flex his hips and knees and ask him to wiggle his toes. Check sensation by lightly poking both sides of his chest, his arms and hands, and his legs and feet with a pin. If you find no weakness or numbness, carefully log-roll him onto his side and thump over his spine from neck to tailbone. Localized tenderness suggests a fracture. Keep him immobilized until you can get him to a hospital.

Pelvis, Hip, and Thigh
When the femur (thigh bone) is fractured, the thigh is swollen, deformed, and very painful, and the victim won't be able to move the injured leg.

Treatment: Grasp the victim's foot and apply steady traction to the leg while an assistant applies counter-traction to the pelvis. When the thigh is straight, strap an oar, paddle, or spar from armpit to beyond the foot, and a shorter splint to the inner thigh from the groin to the foot. Then put some padding under the knees to keep them slightly flexed. If you can't find a splint, strap the victim's legs together.

Hip fractures cause hip or groin pain. Pound the bottom of the victim's heel with your fist. If this produces pain in the groin, he probably has a hip fracture. Pain on movement of the leg and shortening and outward rotation of the leg are also signs of hip fracture.

Treatment: Splint the leg as you would a fractured femur.

Pelvic fractures are rarely obvious. Put one hand over each iliac crest (the large bones on each side at waist level) and press toward the belly button. If this produces pain in the groin, or if there is tenderness to direct pressure over the iliac crests, groin, or pubic area, and if walking is impossible or difficult, the victim likely has a fractured pelvis.

Treatment: Place some padding between her thighs and under her knees, then bandage her knees and ankles together. (See Fig. 2.)

Fractures of the pelvis, hip, and femur bleed internally, and are often associated with severe soft tissue injuries and shock. These people need to be transferred to a hospital.

Kneecap
A contused kneecap will cause swelling and pain, but if you feel crepitus when you press down on the kneecap, it's probably fractured.

Treatment: If there is no deformity, apply a cylindrical splint from groin to ankle and allow the victim to walk. If the kneecap is deformed, and the victim cannot straighten his knee, it may need to be surgically repaired. Apply a compression dressing (several layers of gauze and ABD pads secured with Kling gauze or an elastic bandage) and head for a hospital.

Lower Leg
If you get thrown across the deck and slammed into the scuppers by a Southern Ocean greybeard, you may fracture your tibia (leg bone). Fractures of the upper tibia usually involve the knee joint, which may swell to the size of a mooring buoy. Fractures of the shaft of the tibia are often angulated (bent out of alignment) and open, and the fibula (the smaller bone lateral to the tibia) is usually fractured also.

Treatment: Pull on the ankle until the leg appears straight, then splint it. If bone is protruding from a wound, cleanse the wound with antiseptic solution and apply a sterile dressing before you reduce and splint the fracture.

Ankle
If you find tenderness and crepitus when you press on the bony knobs on both sides of the ankles, you are probably dealing with a fracture and not a sprain. If the foot is discolored and bent at a weird angle, the ankle is fractured and dislocated.

Treatment: Apply padding to the ankle and then secure a SAM splint to the bottom of the foot and up the back of the leg to the knee with an ACE bandage. If you don't have a SAM splint, place a pillow under the ankle and tape it across the front. If the ankle is dislocated, grasp the foot with the heel in your right hand and place your left hand over the top of the foot. Then pull out on the foot until the ankle snaps back into place. The victim will feel better immediately, and normal color will return to the foot as the circulation improves.

Foot
If you fall off the bridge deck and land flat on your feet, you may fracture your heel or the metatarsals (long bones) of your feet. If your back hurts, you may have a compression fractures of the spine also.

Treatment: Apply a large, soft dressing and ACE bandage to the heel and keep it elevated and iced. Wear wooden clogs or stiff-soled boots until metatarsal and big toe fractures heal. (Tape four or five tongue depressors across the sole of the shoe at its widest part to reduce pressure on the fracture.) To treat a fractured toe, insert a wisp of cotton between the toe and its buddy and tape the two toes together.

Dislocations

A dislocated joint is an orthopedic emergency. Blood vessels, nerves, muscles, and ligaments are stretched whenever a bone pops out of joint; the sooner the joint is reduced, the better.

Shoulder
The shoulder can be levered out of joint by a backward force against an elevated arm, such as when you reach up to try to catch a jibing boom. The shoulder has a "squared off" appearance, the arm is held out from the body, and the victim can't place his hand on his uninjured shoulder.

Treatment:

  1. Have the victim lie face-down on the cabin top with the injured arm hanging down and attach 10 to 15 pounds of weight to his wrist with strips of cloth or gauze (see illustration above). The shoulder should slip back in joint within fifteen minutes.
  2. Position the victim as above and sit or kneel next to him. Pull steadily on his upper arm until you feel the shoulder pop back into joint. After you have reduced the shoulder, place the arm in a sling and swathe for three weeks. (See Fig. 3.)

Separated Shoulder
If you trip over some uncoiled line and land on your shoulder, you may disrupt the acromio-clavicular (A-C) joint that joins the end of the collarbone and the shoulder blade (scapula). This is called an A-C sprain, or simply a separated shoulder. In a partial separation, the ligaments that support the A-C joint are incompletely torn and there is moderate swelling and tenderness over the end of the collarbone. In a complete separation, the ligaments are completely torn and the end of the collarbone appears to ride high because it is no longer connected to the scapula.

Treatment: Immobilize the shoulder in a sling until the pain and swelling subside.

Elbow
A hard fall on an outstretched hand may drive the forearm bones backward out of the elbow joint. The elbow will be deformed; if you feel crepitus, it may be fractured and dislocated.

Treatment: If the CMS is good, simply apply ice and put the arm in a sling. However, if you cannot feel a pulse at the wrist and the hand is turning blue, you must reduce the elbow in order to save the arm. Stand in front of the victim and apply steady longitudinal traction on the forearm while an assistant exerts countertraction on the upper arm. After the elbow is reduced, apply a compression dressing to the elbow and immobilize the arm in a sling for two weeks.

Finger
Pull straight out on the digit with one hand and push against the base of the dislocated bone with the thumb of your other hand until the finger is reduced. Then buddy tape it to its partner for 10 days.

Kneecap
Slowly straighten the knee while pushing inward on the kneecap. Once it's reduced, apply a long splint with the knee fully extended.

Hypothermia and Cold-Water Immersion

Hypothermia is a drop in body temperature to below 95 degrees. Unlike snakes and fish, humans and other mammals must maintain a nearly constant body temperature to survive. To do this, the body must balance heat production and heat losses. Body heat is lost through radiation, convection, and evaporation, and is generated by body metabolism. When the core temperature starts to drop, the body responds to the cold challenge by constricting blood vessels in the skin and muscles (creating a cold outer shell that insulates a warm internal core); shivering (which increases heat production up to 500 percent); inhibiting sweating (which limits evaporative heat losses); increasing its blood pressure, heart rate, and respiratory rate; and increasing the basal metabolic rate by increasing muscle tone throughout the body.

The Signs and Symptoms of Hypothermia

    Mild Hypothermia (temperature 90° to 95°)
    The victim is shivering, his speech is slurred, he moves slowly, and his skin is cool. He may be confused and apathetic, and have difficulty handling sheets and lines, or holding navigational instruments.

    Severe Hypothermia (temperature below 90°)
    The victim is dejected and his skin is cold, blue, and mottled. He stops shivering and may hallucinate and act inappropriately, taking off his clothes or jumping in the water. His breathing and heartbeat slow. He becomes profoundly weak, his muscles become rigid, and he stops moving.

Immersion Hypothermia

The good news about cold-water immersion is that you survive longer than you might think. That's also the bad news. Floating in ice water is not unalloyed pleasure. But as cold as you might feel on the outside, your core won't start to cool for at least 15 minutes, even in ice water. Once it does, however, your core temperature will plummet. After an hour and fifteen minutes, it will drop 86 degrees; at that point, you will likely lose consciousness and drown, or die of an irregular heartbeat. The average person can survive for 2.5 hours in 50-degree water, and for up to 12 hours in 68-degree water.

Cold-Water Survival Techniques
You lose body heat about 50 percent faster when you exercise in the water, so trying to swim for shore is rarely a wise move. But you may consider it if you are wearing a PFD and are within a half mile of shore. Generally, your best bet is to get as much of your body out of the water as possible by climbing up on the hull of your boat, if it is still afloat, or flotsam. You may feel colder out of the water, but you will cool much more slowly than you would in the water. If you can't get out of the water, limit skin exposure to the water by assuming the HELP (Heat-Escape-Lessening-Posture) position (See Fig. 4). If you are with a group of people, huddle together and maximize upper body contact. And remember: a powerful will to live is of supreme importance in cold-water immersion.

Rescue and First Aid

A victim of mild hypothermia needs only some dry clothing, a blanket, and a hot, non-alcoholic drink. He'll recover quickly.

If the victim has been in cold water for more than 20 minutes, is lightly dressed, and has been swimming or treading water, treat her for profound hypothermia. Be very gentle with her. Her heart is cold and irritable, and rough handling can precipitate ventricular fibrillation, a lethal heart arrhythmia. If you allow her to move under her own power, or try to rewarm her, she may suffer from "afterdrop" (a sudden drop in core temperature when cold blood surges back to the heart from cold muscles). Carefully move her into the cabin, remove her wet clothing, gently dry her, and cover her with blankets. Then, apply hot packs to her neck, armpits, trunk, and groin, or have two people get undressed from the waist up, get into bed with her, and maintain close chest-to-chest contact. If you can start an intravenous line, infuse warmed (104°) intravenous fluids (Normal Saline or Ringer's Lactate solution). If she is alert, offer her a hot, nonalcoholic drink and something to eat while awaiting evacuation.

Gastrointestinal Problems

Abdominal Pain
Diagnosing the cause of abdominal pain always reminds me of Winston Churchill's description of Russia as "a riddle wrapped in a mystery inside an enigma." Fortunately, as the ship's doctor, you don't have to make a precise diagnosis. Your job is simply to decide whether the patient is well enough to remain on board, or so sick that he needs to be transported to a hospital posthaste. While evaluating your patient, keep these potential causes of abdominal pain in mind.

Problems Inside the Abdomen:

  1. Blockage of hollow organs. The intestine, the gallbladder and its duct, and the ureters can, and frequently do, become blocked. When they do, the result is colicky pain and (usually) nausea and vomiting.
  2. Peritoneal inflammation. The peritoneum is the thin membrane that lines the abdominal cavity. When blood, urine, digestive juices, or bacteria spill onto the peritoneum from a diseased or injured abdominal organ, it becomes inflamed. Appendicitis and cholecystitis often lead to peritoneal inflammation.
  3. Vascular problems. A tear in the aorta in the chest (aortic dissection) or a leaking abdominal aortic aneurysm (stretching and weakening of the wall of the aorta) can cause terrific abdominal pain. A blood clot in the major artery to the intestines (mesenteric thrombosis) will cause pain and shock as the bowel dies.

Problems Outside the Abdomen:

  1. Chest problems. Pneumonia, pneumothorax (collapsed lung), pulmonary embolus, esophageal spasm, and heart attack can all cause pain in the abdomen.
  2. Abdominal wall strain or injury.
  3. Pelvic problems. Ectopic pregnancies, ovarian cysts, and pelvic infections can be perceived as abdominal pain.
  4. 4. Metabolic Problems. Uncontrolled diabetes, spider and scorpion bites, and heavy-metal poisoning can cause abdominal pain.

Digestive System

After you have examined your patient, see if his illness falls into one of the following symptom groups (See Fig. 5.):

  1. Abdominal pain only. Pain is the only symptom early in the course of appendicitis, large bowel obstruction, kidney stone, and gall bladder attack.
  2. Central abdominal pain. Simple intestinal colic, early appendicitis, early small bowel obstruction, pancreatitis, early mesenteric thrombosis, and heart attack.
  3. Severe central abdominal pain and shock. Pancreatitis, mesenteric thrombosis, heart attack, ruptured aortic aneurysm, ruptured spleen, or ruptured ectopic pregnancy.
  4. Pain, vomiting, and distension (no rigidity). Intestinal obstruction.
  5. Abdominal pain, constipation, distension. Large bowel obstruction.
  6. Severe abdominal pain, collapse, and rigidity. Perforation of the stomach or duodenum by a peptic ulcer; rarely, perforation of the gall bladder or appendix.
  7. Right upper quadrant pain and rigidity. Gall bladder attack.
  8. Right lower quadrant pain and rigidity. Appendicitis, kidney infection, ovarian cyst, or tubal pregnancy or infection.
  9. Left lower quadrant pain and rigidity. Diverticulitis, kidney infection, ovarian cyst, or tubal pregnancy or infection.

Some Common Causes of Abdominal Pain

Appendicitis
The appendix is a wormlike thing that hangs down from the colon. Infection of the appendix is called appendicitis. If an appendectomy is not performed within 24 to 48 hours or so, the appendix becomes gangrenous and ruptures, leading to peritonitis, a dangerous condition. The signs and symptoms of appendicitis, in their usual order of onset, include pain (upper or mid-abdominal first), then moving to the right lower quadrant; nausea, vomiting, and loss of appetite; tenderness in the right lower quadrant; rigidity of the abdominal muscles over the appendix; distension in the right lower quadrant; fever (low grade); and constipation. There is but one treatment for appendicitis: surgery.

Gallbladder Attack
Gallstone (biliary) colic begins with agonizing pain in the upper mid-abdomen or right upper quadrant when a gallstone plugs the cystic duct. The pain radiates to the right shoulder blade, and the patient usually vomits and breaks into a cold sweat. The attack usually subsides after the gallbladder expels the stone in one to four hours. In acute cholecystitis the gallbladder can't rid itself of the stone and becomes inflamed and infected. The right upper quadrant pain is aggravated by breathing, coughing, or pressure over the area. There will be a low-grade fever, slight elevation of the pulse, and nausea. There is no effective treatment for gallbladder colic outside of a hospital. Acute cholecystitis is a surgical emergency.

Intestinal Obstruction
An intestinal obstruction is blockage of the normal movement of food and liquids through the intestinal tract. Small bowel obstruction is usually caused by scar tissue from previous abdominal surgery or by bowel becoming trapped in a hernia. Large bowel obstruction can be caused by hard stool in the rectum, by tumors, diverticulitis, or by twisting of a segment of the colon (volvulus).

Intestinal obstructions are bad news. When the intestine becomes blocked, the bowel distends with fluid and gas and loses its ability to absorb water and nutrients. The patient starts to vomit and becomes severely dehydrated. He will die if the obstruction is not relieved.

Signs and symptoms include severe, cramping, midline abdominal pain; nausea and vomiting; abdominal distention; and abdominal rigidity and tenderness and shock if the obstruction is not relieved within several hours. The patient needs to be hospitalized.

Intestinal Hernia
An intestinal hernia is the protrusion of bowel through an abnormal opening, usually in the groin. A reducible hernia is a lump in the groin or abdomen that the patient is able to push back into the abdominal cavity. If the hernia becomes acutely incarcerated, it will be painful and tender, and he won't be able to reduce it. If the blood supply to the incarcerated bowel is compromised, the hernia is said to be strangulated. The patient will exhibit all the signs and symptoms of bowel obstruction.

Treatment: First, place the patient head down in a supine position and apply a warm compress over the hernia for a few minutes. Then gently try to push it back into the abdominal cavity. If you can't reduce it, or if it is tender, head for a hospital.

Hemorrhoids
A hemorrhoid is a varicose vein in the anus. An internal hemorrhoid may cause bright red blood on the stool or toilet paper; if it prolapses (passes out of the anal canal), however, it may become infected or thrombosed, become very painful, and bleed profusely after defecation. When an external hemorrhoid becomes thrombosed it will turn blue and become firm and tender.

Treatment: Warm sitz baths three times a day are the mainstay of treatment. If the thrombosed hemorrhoid has been there for more than 48 hours and is not tense or tender, warm sitz baths and a laxative may do the trick. If the thrombosis has been present for less than 48 hours, and is very painful, surgery may be indicated to give immediate relief. If your patient is incapacitated, he may beg you to excise the clot. Here's how you do it: Have him assume the prone position, then anesthetize the skin over the hemorrhoid with an ice cube. Then use a No. 10 scalpel to make an elliptical incision in the skin over the hemorrhoid and remove the clot with a forceps. Tuck the corner of a small piece of gauze in the wound to control bleeding, and then apply a pressure dressing over it. Remove the dressing and gauze when the patient takes his first sitz bath eight to 12 hours later. If bleeding, pain, or uncontrollable itching become a problem, head for a hospital.

Gastroenteritis
Gastroenteritis is the inflammation of the stomach and intestines, usually secondary to viral or bacterial infection. It causes vomiting and diarrhea which often lead to dehyration.

Treatment: Mild dehydration can be corrected by drinking fruit juices, diluted ginger ale or cola drinks, or a sports drink. If you've had protracted diarrhea and feel lightheaded or dizzy, you need a solution with a higher electrolyte content. You can make up a good oral electrolyte solution by adding 1 tsp. of salt and 8 tsp. of sugar to a liter of water. Drink 8 ounces of the solution, plus as much plain water as you can, every 60 minutes. It's safe to eat staples such as rice, bananas, cereals, lentils, and potatoes, but avoid fats, dairy products, caffeine, and alcohol. You'll know you're rehydrated when you start passing large amounts of clear urine. Loperamide (Imodium) helps to control diarrhea, and promethazine (Phenergan) suppositories put the lid on vomiting. If you have a fever and blood in the stool, you need medical attention.